Sunday, June 28, 2009

The rare syndrome of unilateral left prosopometamorphopsia -- in which the left half of well-known and unfamiliar faces looks distorted -- was reported by Trojano et al. (2009) in a neuropsychological case study:

D.G., a 24-year-old right-handed housewife with 8 years of formal education, suddenly developed severe migraine, confusional state, and blurred vision, mainly in her right visual hemifield, after child delivery. Consciousness returned normal and migraine subsided in a few hours, but the visual disturbances persisted longer.

Repeated EEG recordings showed theta-wave slowing over posterior regions of the left hemisphere. ... Repeated MR did not disclose pathological areas. Brain SPECT (performed 30 min after the injection of 740 MBq of Tc-99m HMPAO) showed reduced blood flow in the inferior and lateral cortex of the left occipital lobe.

D.G. was seen in the clinic 6 months after her stroke, and her right visual field was intact (meaning she did not have damage to the contralateral, or left, primary visual cortex). However,

...she complained that the left half of people's faces (the part on her right side) appeared “out of shape”. D.G. claimed that “the left eye looks elongated towards left ear, the nose appears to be bended towards left cheek and the mouth towards the chin” irrespectively of whether she looked at familiar or unknown people, or even at herself in a mirror. Nonetheless, she reported to be able to recognize relatives and famous people by face, and also to visualise familiar faces in her mind without distortions.

She did not appear to have impairments in other visuospatial perceptual skills, and she could recognize famous faces as well as the control participants did, ruling out prosopagnosia (a face recognition deficit). Interestingly D.G. did not report distortions in the appearance of non-face objects. In a series of experiments, she was impaired in matching pairs of chimeric faces differing in their left halves, but not in a similar condition with chimeric cars. To explain this unusual deficit with a left hemisphere lesion (the right hemisphere is thought to be better at face recognition), the authors speculated that

early stages of face perception proceed in parallel in the two hemispheres and only at late stages the right hemisphere integrates information gathered from both parts of the stimulus to build up an unitary face representation. Replication of such findings and neurofunctional investigations on patients with PMO are warranted to directly verify neural dynamics related to unilateral defects in face processing.

Tuesday, June 23, 2009

In a remarkable preliminary study presented at the 2009 Meeting of the Organization for Human Brain Mapping, scientists at Emory University reported that Republicans were less disgusted by images of torture and human rights violations -- i.e., the infamous Iraq prison photos from Abu Ghraib -- than were Democrats (Hamann et al., 2009). Furthermore, the degree of self-reported arousal while viewing the photos was inversely related to the zealousness of support for Bush and Cheney. The authors speculated that this result may reflect the cognitive dissonance necessary for ardent Republicans to blindly support their cause. In addition, neuroimaging results indicated that for the comparison of Iraq prison photos vs. neutral control photos, the insular cortex was less active in Republicans than in Democrats. This brain region is implicated in interoceptive awareness of bodily states (Craig, 2009), and is responsive to scenes and expressions of disgust (Stark et al., 2007).

...individuals with measurably lower physical sensitivities to sudden noises and threatening visual images were more likely to support foreign aid, liberal immigration policies, pacifism, and gun control, whereas individuals displaying measurably higher physiological reactions to those same stimuli were more likely to favor defense spending, capital punishment, patriotism, and the Iraq War.

That paper was not without its problems, however, as described in my earlier blog post. Nonetheless, the new observations of Hamann et al. are striking: rabid Bush/Cheney fans showed reductions in

both subjective and FMRI-based aversive responses to Iraqi prison photos... in part because of cognitive dissonance elicited by the conflict between support for partisan policies and aversion while viewing consequences attributed to those policies.

Thursday, June 18, 2009

There never was a single "depression gene", and those patting themselves on the back because of the ceremonial defenestration of that straw man are fooling themselves.

Yes, a new meta-analysis in JAMA (Risch et al., 2009) found that a variant of the serotonin transporter gene (the 5-HTTLPR polymorphic region) is not linked to an increased risk of depression, either alone or in combination with stressful life events. This study examined 14 prior papers, including the now-maligned article by Caspi et al. (2003) in Science.

A depiction of the organization of the serotonin transporter showing the 5HTTLPR region and the positions of several SNPs. Adapted from Heils et al, 1996 and Lesch et al, 1996 by the Genotyping Lab at the University of Colorado.

Contrary to popular opinion, Caspi et al. never said that the single gene 5-HTTLPR is the "prime driver" of depression. Instead, they suggested that it moderates the effects of stressful life events on the risk of depression:

Individuals with one or two copies of the short allele of the 5-HT T promoter polymorphism exhibited more depressive symptoms, diagnosable depression, and suicidality in relation to stressful life events than individuals homozygous for the long allele. This epidemiological study thus provides evidence of a gene-by-environment interaction, in which an individual's response to environmental insults is moderated by his or her genetic makeup.

Caspi et al. (2003) also said the following:

Evidence for an association between the short promoter variant and depression is inconclusive. Although the 5-HTT gene may not be directly associated with depression, it could moderate the serotonergic response to stress.

Much genetic research has been guided by the assumption that genes cause diseases, but the expectation that direct paths will be found from gene to disease has not proven fruitful for complex psychiatric disorders.

Until this study's findings are replicated, speculation about clinical implications is premature.

The headlines are predictable enough, "Sad News for Depression Gene" being perhaps the funnest.

But wait; not so fast. Has an empire crumbled here? A hypothesis evaporated?

You need only look at this briefly, I think, to see that the question addressed by both papers is fairly limited, and does not, crucially, cover variations in how early life experiences might amplify any risk conferred by the short 5-HTT allele. (Caspi & Moffitt clearly did not include such events in theirs excluded such early experiences from some of their analyses, and in fact took measures in some of their measures, such as removing from analysis anyone who suffered depression before age 21, that would be likely to exclude some people who suffered particularly rough early years.. And unless I missed something in reading the Risch paper, it too makes no effort to look at early experience in particular -- and, since it pulled Caspi's data from Caspia, would reflect the same possible filtering out of such early-onset depression cases.)

But does anyone still believe that complex psychiatric disorders are caused by a single gene? I think not. The field of psychiatry genetics is littered with examples of "a gene for schizophrenia" and "the gene for bipolar disorder" that have failed to replicate. Even the most ardent proponents have become more circumspect about the search for genes that predispose one to specific mental illnesses.

Hey oncologists: where's "the gene" for cancer? Neurologists, have you found "the gene" for Alzheimer's disease yet? No? Why not? Because they're complex multidetermined diseases. Does that mean there is no role for genetic contributions to these disorders? Of course not! Here's an editorial by Thomas (2005) in Cancer Epidemiology Biomarkers & Prevention:

Thinking about biochemical pathways has become an increasingly important part of molecular epidemiology. The field is rapidly moving from evaluation of single candidate genes, one at a time, to consideration of entire pathways comprising perhaps dozens of genes and their environmental substrates, even multiple pathways that link up or compete in complex networks. Even in its simplest rendering, for example, dietary folate seems to be a protective factor for colorectal cancer and is involved in at least two distinct pathways... Many proteins critical in folate metabolism are coded for by genes with known polymorphisms. Alcohol and vitamins B6 and B12 also play a role in the folate pathway, and of course other pathways involving metabolism of heterocyclic amines, polycyclic aromatic hydrocarbons, bile acids, and nonsteroidal anti-inflammatory drugs might compete or interact with the folate pathways... To further complicate matters, there is evidence that folate may protect against early precancerous lesions but increase the risk of cancer in those with preexisting lesions.

Why should it be any different for bipolar disorder and major depression? Of course a person's life experiences and their environment influence whether or not they develop depression. Given identical circumstances, some people are more likely to become depressed than others. Why is that?

Clinging to the stubborn view that there is absolutely no biological basis for depression is just as preposterous as saying that stressful life events have no influence whatsoever on one's mental health. Get over it.

Sunday, June 14, 2009

HBM draws attendance between 1500-2000 attendees each year. Membership in the organization is growing and the meeting continues be one of the most significant neuroimaging conferences for those in the field.

Saturday, June 13, 2009

The late David Carradine made a surprise guest appearance Tuesday night on Fox's much maligned new show Mental, playing the main mental patient. His character, Gideon Graham, was a professor ["a national treasure"]2 and author of the books Anti-wisdom and the [heavy-handed plot device] Book of Judges. His diagnosis: treatment-refractory catatonia of neuropsychiatric origin following a traumatic injury (being struck by lightning).

According to DSM-IV-TR, catatonia is marked by “motoric immobility, excessive motor activity (that is apparently purposeless and not influenced by external stimuli), extreme negativism or mutism, peculiarities of voluntary movements, or echolalia or echopraxia.” Fink and Taylor (2006) suggest that:

Catatonia, a psychomotor syndrome, is defined in DSM classifications mainly as a subtype of schizophrenia. This identification does not recognize the syndrome’s ubiquitous nature, discourages its recognition in other psychiatric illnesses, and limits treatment to protocols that focus on antipsychotic drugs. We suggest that catatonia be reclassified as an individual abnormal behavior, akin to delirium and dementia.

Professor Graham did not respond to any treatment, including drugs and electroconvulsive therapy (ECT), so the perpetually smirking and supposedly brilliant Dr. Gallagher decides to try transcranial magnetic stimulation (TMS) to awaken him from his stupor. This is not unheard of in catatonic patients, as there are two case studies in the literature that did report some success (Grisaru et al., 1998; Saba et al., 2002). TMS involves the delivery of magnetic pulses to the brain through a specially-designed coil.

Depending on the frequency of the pulses, TMS is thought to induce either excitation or inhibition of the brain tissue below. In the case reports of catatonia, the two patients improved following TMS, then their schizophenia was treated with antipsychotic drugs.

The caps being modeled in the two photos above contain electrodes that record brain waves, or EEG activity, in response to the TMS. This is technically difficult because the magnetic pulses produce a strong electrical field which can saturate the amplifiers. Once these methodological hurdles are overcome, Miniussi and Thut (2009) describe the benefits of combining the two in a research setting:

The TMS-EEG integration provides real-time information on cortical reactivity and connectivity through the analysis of TMS-evoked potentials (TEPs), and how functional activity links to behavior through the study of TMS-induced modulations thereof. It reveals how these effects vary as a function of neuronal state, differing between individuals and patient groups but also changing rapidly over time during task performance.

In a clinical setting, TMS has been most commonly used to treat major depression, when administered in a repetitive fashion (rTMS) over the prefrontal cortex (Padberg & George, 2009).3 TMS differs from ECT in that treatment is administered while the patient is awake, and the occurence of seizures (very rare in those without neurological disorders)4 is a bad side effect, not the desired outcome.

But Mental gets it all wrong... very wrong. First, Dr. Gallagher announces that he has conducted some self-experiments on the sly. So when Gideon's daughter, who is a [unconvincing] supermodel, asks "will it hurt?" Gallagher answers from experience that some will feel "a small tapping sensation." Then Gideon is sedated for the procedure, which isn't normally done. Furthermore, the treatment produces violent seizures, convulsions, and writhing. TMS is not supposed to induce seizures; that would be considered an untoward side effect.5 And finally they keep turning up the field strength beyond recommended levels. At no point did supermodel daughter sign a consent form for such an experimental procedure. "It looks like an execution," she said... "I hope you people know what you're doing."

But this is TV, right, and other shows with medical themes depict ethical violations all the time, right? [Over-the-top plastic surgery show, Nip/Tuck, I'm thinking of you.] Unfortunately, it's not clear what type of show Mental is supposed to be. Is it supposed to be realistic that the brazen Dr. Gallagher literally pushes the evil drug rep out the door? Funny? Cliched, I would say, and that's one of the major problems. Everyone is a walking stereotype, and some of the plot devices are so painfully concrete and literal-minded that you can see them coming a mile away.

For instance, Gideon Graham was struck by lightning while hiking in the Sierras with his wife during a thunderstorm. He survived, she did not. He was trying to teach his wife a lesson in overcoming her fears, because of course going to the edge of cliff in the middle of a fierce thunderstorm is the best type of exposure therapy. And he hates people who are weak.

is a judge appearing in the Book of Judges... The name Gideon means "Destroyer", "Mighty warrior" or "Feller (of trees)".

Thanks, writers, what subtle and complex points you made here! Gideon feels guilty! He judges the world for taking his wife, and himself for his role in her death! In the end, Dr. Gallagher used the "scared straight" approach, yelling at Gideon, removing all reminders of his life, and accusing him of abandoning his daughter. He sets up one final TMS session, which was rigged to be a sham (unbeknowst to everyone but himself). An angry Gideon has supposed "seizures" (with no external stimulation), wakes up, and reaches out to strangle Gallagher, who says "Where's your lightning now?"

Footnotes

1Emmy-nominated for her work in The Sopranos, Annabella Sciorra is by far the best actor in the entire cast.2This was a clumsily dubbed posthumous tribute to David Carradine.

5 However, there is an even newer procedure in limited clinical trials called magnetic seizure therapy (MST), which uses TMS to induce seizures (@vaughanbell). It's being tested as a possible alternative to ECT in treating refractory major depression. The show was not depicting MST, though.

Wednesday, June 10, 2009

Musical hallucinations have been reported in the psychiatric literature, most often associated with schizophrenia, depression, and OCD [also with deafness]. The incidence has been estimated to be somewhere between 0.16% to 27% (Schakenraad et al., 2006). They are less commonly observed during confusional states, when visual hallucinations are more typical. Rentrop et al. (2009) have reported an unusual case study of a 74 year old mathematician and opera buff, who presented at the hospital for emergency surgery of the colon. Shortly thereafter...

...he began to suffer from near complete insomnia and mentioned only briefly that ‘this monkey music’ kept him awake. His condition deteriorated and 5 days later he admitted, that he heard complete operas at night from the very first to the last chord, ‘and you know how long these operas are’. He could not offer any explanation as to where these sounds came from, could not distance himself from his elaborate musical perceptions, had no means of interrupting them, and feared the first notes of another overture (which reliably rang out soon after sunset). On examination during daytime he appeared tired and irritable, rather uncooperative with poor concentration, but without overt evidence of a severe confusional state. His medical history was inconspicuous, but it became obvious that he was a dedicated opera-lover with a profound musical expertise, which he had acquired over decades of studying scores and librettos in every detail.

His labs and CT scan appeared to be relatively normal. The patient was started on the atypical antipsychotic drug olanzapine, and after 7 days:

He regained his strength, became friendly, cooperative, and still appeared puzzled about the vivid orchestrations of his musical memory. His neuropsychiatric status was completely normal at discharge.

The authors ended their Letter to the Editor in deadpan fashion:

"...this is (probably) the first report of a patient with a musical hallucinosis of complete operas."

Sunday, June 07, 2009

Of the various types of abnormal sexual behavior, the most dangerous and bizarre is autoerotic asphyxiation, also known as asphyxiophilia, sexual hanging, sexual asphyxia, scarfing, breath control play, and terminal sex. Though at least one autoerotic asphyxiation death occurs in the United States each day, it is almost unknown as a distinctive psychopathological entity in forensic medicine and psychology.

Dr. Sergey Sheleg and Dr. med. Edwin Ehrlich draw from their own research, as well as the work of others, to provide a comprehensive review of this problem. Bringing together information from a variety of disciplines, Autoerotic Asphyxiation: Forensic, Medical, and Social Aspects is a valuable resource for pathologists, criminal investigators, criminologists, coroners, physicians, attorneys, life insurance experts, and funeral directors, as well as parents and living AEA practitioners.

I thought this book might be of interest in light of reports on the death of actor David Carradine:

First and foremost, it should always be possible to determine how the individual would have intended to control the degree of hypoxia[lack of oxygen] and to escape from the situation. The intention is to survive the ritual not die from it, as might appear at first glance. When death occurs it is almost always due to the failure of a strategy intended to ensure recovery. Many authorities have insisted that a “fail-safe” device is invariably found but in my experience the strategy may often have been simply reliance on subjective judgment, as by releasing hold on a ligature or pulling off a plastic bag, presumably when a feeling of giddiness supervenes.

Second, there must be evidence of sexual activity. Often the body may be found either nude, partially nude, or ... _________.

On his website, Dr. Hucker describes his research on 15 living practitioners of autoerotic asphyxiation (AEA). In his experience,

...living practitioners of hypoxyphilia tend to be articulate and willing to discuss their thoughts, fantasies and motivations in great detail. Surprisingly, perhaps, half of them describe sadistic fantasies. They report that their activities are part of a more elaborate, usually masochistic, fantasy in which they are forced into painful, uncomfortable or humiliating situations. Some individuals have cross gender fantasies and some clearly describe being sexually aroused by being in physical danger and of struggling against physical restraints.

What do we know about David Carradine? The Smoking Gun has uncovered divorce papers filed by his ex-wife, Marina Anderson, who alleged that Carradine engaged in "deviant sexual behavior which was potentially deadly" (and worse, including incest and physical abuse).

Marina Anderson was contacted by TSG, and she stands by her statements.

Not surprisingly, another HUGE part missing from this story was David Carradine’s family being steeped in Scientology. Although David had denied being a Scientologist, he was however, quite the Scientology sympathizer, including multiple performances at at the Scientology Celebrity Center.

[NOTE: Also see this post by "Kung Fool" at alt.religion.scientology]. . .

Where did Carradine’s involvement originate?

Perhaps when Carradine met Milton Katselas at an audition in October 1960. Katselas was a producer and acting coach at the Beverly Hills Playhouse and was renown for ruthlessly indoctrinating his students into Scientology by using a lot of pressure. Katselas told his students that they would improve their careers and make more money if they got into Scientology, when in fact the only one getting richer was Katselas, who was surely compensated by Scientology for every celebrity cash cow he delivered.

Carradine’s FIFTH wife, Ann Bierman, (since 2004) is an OTV in Scientology. She has a Scientology Web page set up, (set up by Scientology that is) where she states that Scientology has made her drug free.

Back to his death. Was it really an AEA accident, or was it suicide, or ...murder?

Which one do you like best, dear readers? Please reply in the comments and vote online at 3QD. Of these, Voodoo Correlations in Social Neuroscience is currently in the lead with a grand total of 259 18 votes[I know, very sad] so why not you cast your vote for that entry? Any and all votes will be greatly appreciated! [but you can only vote once, so make it count.]

The voodoo post was one of many to highlight the controversial paper by Ed Vul and colleagues, since renamed "Puzzlingly High Correlations in fMRI Studies of Emotion, Personality, and Social Cognition" (PDF). The authors questioned the implausibly high correlations observed in some fMRI studies in the field of Social Neuroscience. A new look at the analytic methods revealed that over half of the sampled papers used faulty techniques to obtain their results. The authors' early online release of the accepted manuscript, combined with spirited debate in the blogosphere, caused many to praise (and damn) the role of blogs in discussing and critiquing peer-reviewed scientific literature.

Results of the voting round (the top twenty most voted for posts) will be posted on the main page on June 8, 2009. Winners of the contest, as decided by Steven Pinker, will be announced on June 21, 2009.

Vincent, the paranoid schizophrenic artist who draws little green men and has visual hallucinations [not the more typical auditory sort], was found screaming and wandering naked in traffic.

The summer replacement series with the un-PC name1 is about life in a psychiatric inpatient unit:

MENTAL is a medical mystery drama featuring Dr. Jack Gallagher, a radically unorthodox psychiatrist who becomes Director of Mental Health Services at a Los Angeles hospital where he takes on patients battling unknown, misunderstood and often misdiagnosed psychiatric conditions. Gallagher delves inside their minds to gain a true understanding of who his patients are, allowing him to uncover what might be the key to their long-term recovery.

Unfortunately, the pilot episode was absolutely terrible, just one stereotype after another, with the brave unorthodox heroic psychiatrist opposing the shrew-like female staff and suggesting that herbs and acupuncture are the best treatment for paranoid schizophrenia.

Vincent the mental patient is unnaturally strong and cannot be subdued by several cops and hospital administrators. So the rakish Dr. Gallagher strips naked to gain his trust as a fellow human, joined together in the fight against the scary lizard people.

The acting was bad, the writing was awful, and the characters were unappealing. The situations were wildly unrealistic: psychiatry residents are sent on a house call (fact-finding mission), Gallagher is arrested for breaking into Vincent's home to see his outsider art, and the inexplicable charisma of Gallagher and his ways manages to change the mind of one female colleague who had actually resigned in protest (no matter that her turnaround was nearly nonsensical).

After breaking and entering, Dr. Gallagher views his patient's outsider art for the first time. The tortured artist Vincent had completely lost his creativity due to zombifying antipsychotic medications that, nonetheless, allowed him to function in society and live with his sister and her kids.

The show makes the unfortunate suggestion that drugs are all bad.2 Gallagher guilt-trips the sister into accepting his new-age treatment plan for Vincent, who otherwise must make the ultimate sacrifice (loss of his artistic abilities, minimal though they are) of resuming medication.

And here's the drug-free Vincent, drawing for the first time in ages while his sister looks on.

meaning someone who is silly or stupid, usually for attention and in a random or sporadic way, involving nonsensical references and actions. usually violent or quick action involved, resulting in general amusement and hilarity of onlookers.

"hey look, archie's jumping off that cliff while holding a banana!""wow! he's mental!"

About Me

Born in West Virginia in 1980, The Neurocritic embarked upon a roadtrip across America at the age of thirteen with his mother. She abandoned him when they reached San Francisco and The Neurocritic descended into a spiral of drug abuse and prostitution. At fifteen, The Neurocritic's psychiatrist encouraged him to start writing as a form of therapy.